Article type : Case Report | تاریخ ثبت : 2015/01/19

This is to report a rare case of enterococcal pneumonia and pleural effusion in a 32-year-old woman with severe and active dermatomyositis. She developed fever, respiratory failure, and pleuritic chest pain for 12 days before admission to our hospital. Chest X-ray showed increased overall density of the right hemithorax, indicative of pleural effusion and consolidation with air bronchogram. Cultured pleural drainage revealed growth of Enterococcus faecalis. The patient was treated with imipenem and intravenous immunoglobulin (IVIG) and corticosteroid and the patient’s response to treatment was very good. Chest radiography and chest (computed tomography) CT scan after treatment was quite clear. Enterococci rarely cause pneumonia and plural effusion in general population but it can be concluded that in patients with inflammatory myopathic disease who are treated with immunosuppressive drugs may be a factor of respiratory tract infection.

INTRODUCTION

Polymyositis (PM) and dermatomyositis (DM) are systemic inflammatory disorders affecting skeletal muscles and other organs.2-4 PM and DM are consid-ered to be associated with high morbidity and mortal-ity rates, primarily related to life-threatening muscle weakness, cardiac and lung impairment, as well as infectious manifestations.1–5 In clinical series of pa-tients with PM/DM, infectious complications have been described in up to 26% of patients.4, 6 Several factors may be implicated in this apparent in-creased frequency of infections in PM/DM patients, particularly on immunosuppressive medications. In addition, immune system dysfunction, due to PM/DM itself, may lead to elevated susceptibility to infections.The association between PM/DM and opportunistic infections has rarely been described in the literature.4 As these patients exposed to high doses of corticoste-roids and cytotoxic drugs therefore they are prone to many serious infections. Various viral and fungal in-fections also contribute to the morbidity and mortal-ity associated with these condition. Keeping in mind the possible role of unusual infections might be very helpful. Our patient suffered from pneumonitis and pleural effusion by enterococcal faecalis that is a rare infection in respiratory system without primary focus after abdominal surgery or endocarditic, therefore Correspondence: Simin Almasi Department of rheumatology, Rheumatology Re-search Center, Firoozgar Hospital, Iran University of Medical Sciences(IUMS), Tehran, Iran. E-mail: simin_almasi@yahoo.com this case is interesting in this regard. Thus, patients receiving high doses of corticosteroids and immuno-suppressive therapy, need to be monitored closely for these infections.

CASE REPORT

A 32-year-old white woman presented with 12-days history of right-sided pleuritic chest pain. She also had dyspnea, fever and chills, anorexia, cough and tachypnea. The patient was a known case of severe DM with criteria including weakness, elevated mus-cle enzyme, typical skin lesion (Gottron’s papules, malar rash and heliotrope rash), myopathic pattern in electromyography and positive muscle biopsy since 10 months ago. She had received high doses of cor-ticosteroids, hydroxychloroquine and azathioprine and monthly IVIG for 6 courses. She had no histo-ry of urinary tract infection or abdominal surgery in the past. On examination, the oral temperature was 38.1◦C and the chest wall was dull to percussion with diminished breath sounds at the base of right lung. Proximal muscle forces was 3/5 in upper and low-er extremities. The rest of the examination was un-remarkable. Chest radiography showed right pleural effusion (Fig. 1). Laboratory data were notable for an elevated leuko-cyte count of 12,000 × 103 / µL with 90% of poly-morphonuclears (PMN), and an erythrocyte sedimen-tation rate (ESR) of 40 mm/h (normal, 0 -15 mm/h), CRP +2, CPK 853 (normal, 450 -100 U/L), LDH 1300 (normal and no vegetation on cardiac valves. After 3 days, her symptoms were bet-ter and fever, chills, dyspnea got improved. Repeated CT scan of lung 3 weeks later showed that pleural effusion and consolidation had been resolved (Fig. 3).

DISCUSSION

Enterococci are gram-positive cocci, which may play a pivotal role in a variety of community- and hos-pital-acquired infections, the main cause of bacterial infection in the urinary tract, primary bacteremia and endocarditis and lower respiratory tract infections caused by enterococci are very rare.5 Most humans and animals have enterococci in their intestinal tract. Enterococci, particularly Enterococcus faecalis, are a common cause of endocarditis (5 to 15 percent of community-acquired endocarditis and up to 30 per-cent of nosocomially-acquired endocarditis) and can be a common cause of nosocomial urinary tract in-fections (being recovered from up to 15 to 20 percent of UTIs in the hospital setting).6 Incidence of pleural empyema due to enterococci is only 4% of all entero-coccus infections and enterococcal empyema is rare. Most cases were patients who had undergone recent abdominal surgery or were suffering from liver cir-rhosis and/or associated peritonitis, while ours does not have this background. The source of infection was reported as endocarditis with spleen abscess in one case and esophago-pleural fistula after pneumo-nectomy in the other. In the other 28 reported cases, the origin of enterococci was never identified.7 In-advertent use of antibiotics has been led to resistant enterococci to several types of antibiotics including aminoglycosides and cephalosporins that may lead to unusual clinical presentations and complications as we described.8 Enterococci are the second to third most common organisms isolated from hospital-acquired (nosoco-mial) infections, particularly in more severely ill pa-tients who have been hospitalized for long period of time and/or have received multiple antibiotics.9 A sig-nificant proportion of enterococci are E. faecium that have been implicated in up to 40 percent of blood-stream isolates in high risk populations such as liver or stem cell transplant recipients.10 Enterococci also have intrinsic factors such as a number of potential adhesion genes, which may explain the propensity to cause endocarditis.11

CONCLUSION

Enterococcal-associated lower respiratory tract infec-tions are rarely reported, but may be underestimated. Physicians should consider their occurrence in severe or non-resolving cases of pneumonia.